Substance use (MRCP)

Question 1

According to Jellinek’s classifi cation of alcoholism, which of the following
types refers to a person who has developed physical and psychological
dependence but still maintains the ability to abstain if necessary?
A. Alpha
B. Beta
C. Gamma
D. Delta
E. Epsilon

Answer 1

C. According to Jellinek, drinking behaviour is heterogeneous. He described fi ve species
of alcoholism. Type alpha represents a purely habitual use without loss of control. A person
with alpha alcoholism retains the ability to abstain. Type beta refers to development of physical
complications without physical or psychological dependence. Type gamma represents acquired
tissue tolerance leading to physical dependence and loss of control. They still maintain the ability
to abstain if necessary. Type delta shares the three features of gamma, but the inability to abstain
becomes prominent. Type epsilon refers to dipsomania or periodic alcoholism. More recently,
various investigators have come up with different classifi cations, which overlap each other.

Question 2

Which of the following is NOT a criterion for alcohol dependence
syndrome as described by Edwards and Gross?
A. A subjective awareness of compulsion to drink
B. Increased tolerance to alcohol
C. Repeated withdrawal symptoms
D. Relief or avoidance of withdrawal symptoms by further drinking
E. Reduction in social obligations

Answer 2

e

Question 3

Which of the following is NOT a diagnostic criterion for alcohol
dependence according to DSM-IV?
A. Strong desire or sense of compulsion to drink alcohol
B. Tolerance
C. Withdrawal
D. Loss of normal social activities due to drinking
E. Continued intake despite knowledge of the harmful effect

Answer 3

A. ICD-10 includes six items under dependence, most of which are similar to DSM-IV. For
a diagnosis of dependence, three or more items should have occurred in the past year. The
‘strong desire or sense of compulsion to take the substance’ is viewed as a central descriptive
characteristic of dependence in ICD-10. This compulsive-use indicator is not included in the
concept of dependence described by DSM-IV. DSM-IV also allows categorization of substance
dependence with or without physiological dependence depending on the presence of tolerance
and withdrawal symptoms

Question 4

The mortality rate in a person being treated for alcohol withdrawal
delirium is
A. 0–1%
B. 10–20%
C. 20–30%
D. 30–40%
E. >50%

Answer 4

A. Alcohol dependence occurs in 15–20% of hospitalized patients in some settings. Hence
withdrawal from alcohol is also a common presentation in this population. Withdrawal symptoms
are minor in most cases, but they can be considerable and even fatal in some. Alcohol withdrawal
delirium, commonly known as delirium tremens or ‘DTs’, is the most serious manifestation of
alcohol withdrawal syndrome. Classic studies quote a mortality of around 15%, but with advances
in treatment, mo

Question 5

What is the typical time period in which withdrawal delirium appears in an
alcohol-dependent person who has stopped drinking?
A. Within 6 hours
B. 6–12 hours
C. 2–3 days
D. After 7 days
E. 2 weeks

Answer 5

C. Clinical features of alcohol withdrawal syndrome can appear within hours of the last
drink (usually 6–12 hours) but alcohol withdrawal delirium typically does not develop until
2–3 days after cessation of drinking. Delirium tremens usually lasts 48–72 hours, but can last
longer in some cases. Current diagnostic criteria for withdrawal delirium include disturbance of
consciousness, change in cognition or perceptual disturbance developing in a short period, and
the emergence of symptoms during or shortly after withdrawal from heavy alcohol intake. The
classic clinical presentation also includes hyperpyrexia, tachycardia, hypertension, and diaphoresis.
The neurobiological basis for withdrawal is a gradual upregulation of N-methyl-D-aspartate
receptors under the infl uence of chronic alcohol use.

Question 6

A patient who was found to be unconscious on the roadside was brought to
the A&E. While transporting him, he had a seizure in the ambulance. Which
of the following best points towards a diagnosis of generalized epilepsy
rather than a seizure associated with alcohol-related complications?
A. Electrolyte disturbances
B. Hypoglycaemia
C. Occult subdural haematoma
D. Presence of illicit substances in the drug screen
E. Generalized spikes and waves on the inter-ictal EEG

Answer 6

E. This question looks at the possible differential diagnoses in a case of alcohol-related
seizure. All the given choices are results of laboratory investigations that may give us a clue of the
possible cause for the seizure. Electrolyte imbalance, hypoglycaemia, subdural haematoma, and
other substances in blood may be associated with an alcohol-induced seizure. EEG is useful in the
setting of the fi rst alcohol withdrawal seizure or where epilepsy is suspected, but not immediately
after a seizure when a record of slow delta activity is found whatever the cause of the seizure.
However, the inter-ictal EEG is usually within normal limits in alcohol withdrawal seizures,
whereas a generalized spike and wave (epileptiform activity) patterns on the EEG points towards
generalized epilepsy. Alcohol-related seizures do not predispose to epilepsy.

Question 7

Which of the following is the treatment of choice for status epilepticus in a
case of alcohol withdrawal?
A. Diazepam
B. Chlordiazepoxide
C. Lorazepam
D. Carbamazepine
E. Phenytoin

Answer 7

C. Benzodiazepines are the fi rst-line treatment in alcohol withdrawal seizures. Lorazepam
has been found to be superior to placebo in double-blind placebo-controlled studies of patients
with chronic alcohol abuse presenting with a generalized seizure. The European treatment
guidelines recommend either diazepam or lorazepam, although lorazepam is recommended over
diazepam in the setting of status epilepticus. This is because lorazepam (although it has a shorter
half-life than diazepam) maintains a steady plasma state for a longer time than diazepam, which
is lipid soluble. The plasma levels of diazepam drop rapidly due to redistribution to fat. Placebocontrolled
trials have demonstrated phenytoin to be ineffective in the secondary prevention of
alcohol withdrawal seizures.

Question 8

Which of the following is a relative contraindication in a case of alcohol
withdrawal delirium?
A. Diazepam
B. Lorazepam
C. Haloperidol
D. Chlorpromazine
E. Chlordiazepoxide

Answer 8

D. General guidelines on the management of alcohol withdrawal advise against the use of
neuroleptic agents as the sole pharmacological agents in the setting of delirium tremens, as they
are associated with a longer duration of delirium, higher complication rate, and, ultimately, a higher
mortality. However, neuroleptic agents have a role as a selected adjunct to benzodiazepines
when agitation, thought disorder, or perceptual disturbances are not suffi ciently controlled
by benzodiazepines. Although haloperidol is well established in this setting, chlorpromazine
is contraindicated as it is more epileptogenic. There is little information available on atypical
antipsychotics in this regard.

Question 9

Failure to diagnose and failure to institute adequate thiamine replacement
therapy for Wernicke’s encephalopathy is associated with a mortality of
nearly
A. 5%
B. 10%
C. 20%
D. 30%
E. >50%

Answer 9

C. Failure to identify or consider Wernicke’s encephalopathy, and failure to institute adequate
thiamine replacement therapy, has an associated mortality of 20%. Wernicke’s encephalopathy
is an acute neuropsychiatric condition associated with biochemical brain lesion caused by the
depletion of intracellular thiamine (vitamin B1). Although reversible in the early stages, continued
depletion leads to cellular energy defi cit, focal acidosis, regional increase in glutamate, and
ultimately cell death. Ninety per cent of the cases in developed countries are associated with
alcohol misuse. This defi ciency may be due to dietary defi ciency, reduced absorption, and the
increased excretion of thiamine seen in alcohol users. Clinical features include delirium with
prominent anterograde amnesia, ataxia, and ophthalmoplegia. Imaging may reveal the presence of
small haemorrhages in mamillary bodies and thalami.

Question 10

If left untreated what percentage of people who develop Wernicke’s
encephalopathy goes on to develop a severe persistent amnestic syndrome
(Korsakoff ’s dementia)?
A. 5%
B. 10%
C. 20%
D. 40%
E. 75%

Answer 10

E. Seventy-fi ve per cent of cases with Wernicke’s encephalopathy will be left with
permanent brain damage involving severe short-term memory loss (Korsakoff ’s dementia)
if adequate parenteral therapy with thiamine is not instituted. In clinical practice, Wernicke’s
encephalopathy may be diffi cult to recognize because all the classic symptoms may not be
present. In addition, the symptoms may be coloured by the presence of other comorbidities such
as withdrawal delirium or seizures. Some authors also suggest the presence of a subsyndromal
version of the encephalopathy that may present only with minor symptoms and neuroimaging
fi ndings. Twenty-fi ve per cent of patients with Korsakoff ’s dementia will require long-term
institutionalization.

Question 11

A severely malnourished patient is admitted to hospital for planned surgery.
He develops alcohol withdrawal delirium. He has no signs of Wernicke’s
encephalopathy. Which of the following is the best strategy for thiamine
replacement in this patient?
A. Oral thiamine 30 mg three times daily for 5 days
B. Oral thiamine 50 mg three times daily for 5 days
C. Intravenous thiamine 300 mg three times daily for 5 days
D. Intramuscular thiamine 50 mg three times daily for 5 days
E. Thiamine is not required as the patient has not developed Wernicke’s encephalopathy

Answer 11

C. Risk factors for developing Wernicke’s encephalopathy include a greater degree of
malnutrition and severity of alcohol misuse. Oral thiamine hydrochloride cannot be relied on to
provide adequate thiamine to patients at risk. This is because studies show that only a maximum
of 4.5 mg of thiamine will be absorbed from an oral dose over 30 mg. In addition, patients with
alcohol problems tend to have poor absorption. Therefore, intravenous delivery of high-potency
B-complex vitamin therapy containing thiamine remains the standard of care for those patients
with suspected Wernicke’s encephalopathy (500 mg of thiamine three times daily for three days),
or who are at risk for Wernicke’s encephalopathy (250 mg three times daily for 3–5 days). In the
outpatient setting, the administration of a course of intramuscular thiamine 200 mg for 5 days has
been recommended because the absorption of thiamine is negated further by continued drinking
after hospital discharge.

Question 12

Which of the following is not a risk factor for suicide in an
alcohol-dependent individual?
A. Male gender
B. Age less than 50 years
C. Recent interpersonal loss event
D. Poor social circumstances
E. Polysubstance use

Answer 12

B. Up to 40% of people with an alcohol use disorder attempt suicide at some time and
7% end their lives by committing suicide. Risk factors include being male, older than 50 years
of age, living alone, being unemployed, poor social support, interpersonal losses, continued
drinking, consumption of a greater amount of alcohol when drinking, a recent alcohol binge,
previous alcohol treatment, a family history of alcoholism, a history of comorbid substance
abuse (especially cocaine), a major depressive episode, serious medical illness, and prior suicidal
behaviour. Suicidal behaviour is especially frequent in patients with comorbid alcoholism and
major depression.

Question 13

Lifetime prevalence rates of alcohol use disorder is highest in
A. Bipolar disorder
B. Schizophrenia
C. Panic disorder
D. Major depression
E. Generalized anxiety disorder

Answer 13

A. Alcohol use disorder co-occurs with other major mental illnesses. The Epidemiology
Catchment Area Study reported a 13.8% lifetime prevalence for alcohol abuse or dependence in
persons with bipolar I disorder in the US general population. Lifetime prevalence of alcohol abuse
or dependence are: bipolar I, 46.2%; bipolar II, 39.2%; schizophrenia, 33.7%; panic disorder, 28.7%;
unipolar depression, 16.5%. Patients with mania had an odds ratio of 6.2 (highest) for
co-occurring alcohol abuse and/or dependence. Considering the degree of psychiatric
comorbidity among alcohol-dependent individuals, the National Comorbidity Survey showed
that the odds ratio (OR) of having co-occurring lifetime diagnosis of mania in patients with a
lifetime diagnosis of alcohol dependence was higher in both men (OR = 12.03) and women
(OR = 5.3).

Question 14

Psychosocial interventions available for alcohol dependence include
motivational enhancement therapy (MET), cognitive behavioural therapy
(CBT) and 12-step facilitation programmes (TSF). Which of the following is
NOT correct with regard to these interventions?
A. Four sessions of MET were found to be equivalent to 12 sessions of CBT
B. MET was more cost-effective than CBT
C. High levels of anger at baseline predicted better outcomes with CBT than MET
D. Participants in Alcoholics Anonymous (AA) responded better with TSF than MET
E. ‘Meaning-seeking’ patients fared better on TSF than MET

Answer 14

C. This question can be answered using results from a study called Project MATCH
(Matching Alcoholism Treatments to Client Heterogeneity). MATCH is one of the largest
randomized trials to have examined psychosocial interventions for people with alcohol-related
problems. The study is a multicentric study that involved randomizing over 1700 patients to MET,
CBT, or TSF. This study demonstrated that four sessions of MET were as effective for treating
alcohol dependence as 12 sessions of CBT or TSF therapy. The benefi ts from treatment persisted
for up to 3 years. Clients with a higher degree of baseline anger fared better with MET than CBT
or TSF. MET was found to be more cost-effective than CBT or TSF.
The Project MATCH study and smaller patient-matching studies provide support for the
effectiveness of TSF programmes. Patients in Project MATCH who received outpatient TSF were
most likely to abstain from alcohol during the fi rst post-treatment year. TSF therapy led to a
greater length of time before the patient’s fi rst relapse and to a higher percentage of abstinent
patients at 1- and 3-year follow-up. Patients in Project MATCH with social networks supportive
of not drinking responded better to TSF than MET, and that participation in AA was a mediator
of this effect. Project MATCH found that patients who were rated high in ‘meaning-seeking’ fared
better with TSF than CBT and MET at 1-year follow-up.

Question 15

Which of the following clients are the most suitable for using brief
interventions for alcohol use?
A. Problem drinkers attending primary care
B. Prisoners with physical health problems due to alcohol use
C. Moderate alcohol dependence
D. Severe alcohol dependence
E. Relapse prevention therapy following achievement of abstinence

Answer 15

A. Brief interventions are recommended for reduction of alcohol use for patients across
age and gender who are heavy or problem drinkers and do not meet the criteria for severe
alcohol dependence. Brief interventions are intended to be conducted by health professionals
who usually are not involved in addiction treatment, e.g. clinicians in general medical and other
primary care settings. Brief interventions may differ in intensity from a single 5-minute session of
simple advice to stop drinking to multiple sessions lasting up to 60 minutes each. They generally
consist of four or fewer visits. They are generally useful for the prevention of alcohol-related
problems in patients who are at risk of developing them. They are not primarily used as a
maintenance therapy for fully fl edged alcohol use disorders like dependence. The content of brief
interventions can be remembered using the acronym FRAMES developed by Miller and Rollnick:
feedback about the adverse effects of alcohol; emphasis on personal responsibility for changing
the dysfunctional behaviour; advice about reducing or abstaining from the behaviour; a menu of
options for further help; empathic stance towards the patient; and an emphasis on self-effi cacy.

Question 16

In Aus, one unit of alcohol is equivalent to which of the
following?
A. 4 grams of pure alcohol
B. 6 grams of pure alcohol
C. 10 grams of pure alcohol
D. 12 grams of pure alcohol
E. 24 grams of pure alcohol

Answer 16

c

Question 17

Which of the following is incorrect with regard to the pharmacokinetics of
alcohol?
A. Most alcohol is absorbed from the small intestine
B. Pylorospasm can reduce the amount of absorption
C. Women are less likely to get intoxicated than men for a given dose
D. A fi xed amount of alcohol gets metabolized in the liver irrespective of plasma
concentration
E. Absorption of alcohol is inhibited by the presence of food in the stomach
18. Which of the following has been found to be the best screening method for

Answer 17

C. Nearly 90% of alcohol is absorbed from small intestine, with the remaining 10%
absorbed from the stomach. Alcohol reaches peak blood concentration approximately
45–60 minutes after consumption. Absorption is enhanced by an empty stomach whereas
food delays absorption. When the alcohol concentration in the stomach becomes too high,
gastric mucus secretion increases, leading to closure of the pyloric valve. This pylorospasm
slows down the absorption and protects from rapid intoxication but can lead to vomiting
and nausea in drinkers.
The intoxicating effects are greater when the blood alcohol concentration is rising than when it
is falling; this is called the Mellanby effect. As a result, the rate of absorption directly affects the
intoxication response. Nearly 90% of absorbed alcohol is metabolized through oxidation in the
liver; the remainder is excreted unchanged by the kidneys and lungs. The rate of oxidation by
the liver is constant (15 mg/dL per hour) and independent of plasma alcohol levels; thus alcohol
follows zero-order elimination kinetics. Women have a tendency to become more intoxicated
than men after drinking the same amount of alcohol; this may be due to differences in absorption
kinetics and a lower level of metabolic enzymes such as alcohol dehydrogenase (ADH) in
women.

Question 18

Which of the following is true with regard to alcoholic blackouts?
A. They consist of discrete episodes of anterograde amnesia
B. Loss of memory for the remote past is a characteristic feature
C. Acute thiamine depletion is the causative factor
D. Alcoholic blackouts are rare among binge drinkers
E. Epileptiform activity is almost always noted in EEG during blackouts

Answer 18

A. AUDIT is a 10-item questionnaire, covering quantity, frequency, inability to control
drinking, withdrawal relief, loss of memory, injury, and concern by others. A score of 8 or more
indicates that the person is drinking to a degree that is harmful or hazardous, whereas a score
of 13 or more in women and 15 or more in men is indicative of dependent drinking. It is a very
useful and widely used scale. The CAGE questionnaire is a simple, easily administered instrument
that has only four items. A positive answer should raise suspicion of an alcohol problem, and
a score of 2 is highly suggestive of one. It takes 30–120 seconds to administer. Aertgeerts et al
studied alcohol screening instruments used in general practice. They found that CAGE was an
insuffi cient screening instrument for detecting alcohol misuse or dependence among primary
care patients with only 62% sensitivity for males and 54% for females. AUDIT was found to be
more effective, with a sensitivity of 83% among males and 65% among females. However, this
was using a cut off-point of 5 rather than the usual 8. The study also found that conventional
laboratory tests are of no use for detecting alcohol abuse or dependence in a primary care
setting. MAST is the Michigan alcohol screening test and the other options in the question are
laboratory-based blood tests

Question 19

Which of the following is true with regard to alcoholic blackouts?
A. They consist of discrete episodes of anterograde amnesia
B. Loss of memory for the remote past is a characteristic feature
C. Acute thiamine depletion is the causative factor
D. Alcoholic blackouts are rare among binge drinkers
E. Epileptiform activity is almost always noted in EEG during blackouts

Which of the following is least likely to be a presenting physical feature of a
child with foetal alcohol syndrome (FAS)?
A. Macrocephaly
B. Learning disability
C. Absent philtrum
D. Syndactyly
E. Atrial septal defect

Answer 19

A. Alcohol-related blackouts are similar to episodes of transient global amnesia; they occur
as discrete episodes of anterograde amnesia in association with alcohol intoxication. Despite
a specifi c short-term memory defi cit (inability to recall events that happened in the previous
5–10 minutes) during the blackouts and signifi cant subjective distress that follows, patients have
relatively intact remote memory and can perform complicated tasks during a blackout. Thus they
appear completely normal to casual observers. It is thought that alcohol blocks the consolidation
of new memories into old memories via its action on medial temporal structures. Binge drinkers
may be particularly prone to alcoholic blackouts due to repeated intoxications. Although amnesia
may accompany withdrawal or intoxication-related generalized seizures, not all blackouts are
associated with epileptic activity in EEG.

Question 20

Which of the following is least likely to be a presenting physical feature of a
child with foetal alcohol syndrome (FAS)?
A. Macrocephaly
B. Learning disability
C. Absent philtrum
D. Syndactyly
E. Atrial septal defect

Answer 20

A. Children with FAS commonly present with microcephaly rather than macrocephaly. It is
well documented that alcohol and its metabolite acetaldehyde can have serious effects on the
developing foetus. Currently, the estimated incidence of FAS is between 1 and 3 cases per 1000
live births. It is one of the most frequent causes of birth defects associated with learning disability,
and the most common of non-hereditary causes of birth defects. Clinical features of FAS include
prenatal and postnatal growth retardation, central nervous system abnormalities, usually with
learning disability (up to severe), a characteristic facial dysmorphism (e.g., absent philtrum,
fl attened nasal bridge, short palpebral fi ssures, epicanthic folds, and maxillary hypoplasia), and
an array of other birth defects such as microcephaly, altered palmar creases, short stature,
syndactyly, atrial septal defect and other heart abnormalities. Full-blown foetal alcohol syndrome
is seen in the offspring of approximately one-third of alcoholic women drinking the equivalent of
10–15 units daily. It is also more common in women who binge drink.

Question 21

Mr White is an 80-year-old gentleman who has been taking diazepam at a
dose of 20 mg at night for the past 3 years. During a trip to France to meet
his nephew, he forgets to take his medication. Which of the following is
NOT likely to be a seen if he experiences benzodiazepine withdrawal?
A. Delirium
B. Anxiety
C. Bursts of high-frequency activity on the EEG
D. Insomnia
E. Nightmares

Answer 21

C. Sedative-hypnotic (includes benzodiazepines, barbiturates and newer ‘z’ hypnotics)
withdrawal syndrome is a spectrum of signs and symptoms that occurs after stopping daily
intake of a sedative-hypnotic. Common signs and symptoms include anxiety, tremors, nightmares,
insomnia, anorexia, nausea, vomiting, postural hypotension, seizures, delirium, and hyperpyrexia.
The withdrawal syndrome is similar for all sedative-hypnotics, but the severity and time course
depend on the pharmacokinetics of the individual agent used, besides a number of other risk
factors. With short-acting medication, withdrawal symptoms typically begin 12–24 hours after
the last dose and peak in intensity between 24 and 72 hours after the last dose. If the patient
has liver disease or is over the age of 65, symptoms may develop more slowly. With long-acting
medication, the withdrawal syndrome usually begins 24 to 48 hours after the last dose and peaks
on the fi fth to eighth day. During untreated sedative-hypnotic withdrawal, the EEG may show
bursts of high-voltage, low-frequency activity. This may precede a clinical seizure occasionally.

Question 22

Polymorphisms of genes encoding which of the following enzymes/receptors
confers protection from alcohol dependence in certain ethnic groups?
A. Aldehyde dehydrogenase (ALDH)
B. Amino acid dehydrogenase
C. GABAA receptor
D. CYP3A4 enzyme
E. HLA-DR2 protein

Answer 22

A. ADH (alcohol dehydrogenase) and ALDH (aldehyde dehydrogenase) are the major
enzymes involved in the degradation of ethanol; ADH catabolizes alcohol to acetaldehyde, which
ALDH breaks down to acetate and water. A number of studies have shown that allelic variants
of ADH and ALDH are associated with the risk for developing alcohol dependence. There are
many ALDH gene families distributed on several different chromosomes. Family 2 genes (ALDH
2) located on chromosome 12 have been studied the most regarding an association with alcohol
dependence. This family of genes encodes mitochondrial enzymes that oxidize acetaldehyde.
ALDH 2 has an allelic variant called ALDH 22. This ALDH 22 variant is found in approximately
50% of the Asian population. Individuals with the ALDH 22 variant typically experience a
disulfi ram-like reaction when they take alcohol. This is sometimes called the ‘Asian fl ush’ or the
‘Oriental fl ush syndrome’. Several studies demonstrate the protective effect of ALDH 22 gene
carriers from developing alcohol dependence. The other genes ALDH1, 3, 4 and 5 are responsible
for the metabolism of other aldehydes in the body. Similarly a variant allele of the ADH gene
(situated on chromosome 4) ADH 22 also confers protection to alcoholism, although this
relationship is less robust than ALDH22.

Question 23

Which of the following statements regarding alcohol use and comorbid
depression is correct?
A. 10–20% of clients who use alcohol have at least one episode of depression in their
lifetime
B. Abstinence from alcohol does not lead to recovery from depression
C. Women with alcohol problems have more comorbid depression than men
D. Alcohol reduces the likelihood of successful completion of suicide among the depressed
E. Risk of depression is independent of the amount of alcohol consumed daily

Answer 23

C. About 30–40% of people with an alcohol-related disorder meet the diagnostic criteria
for a major depressive disorder sometime during their lifetime. It is more common in women.
It is dose dependent, i.e. it is likely to occur in patients who have a high daily consumption of
alcohol. It is also more common in those with a family history of alcohol abuse. Patients with
depression and comorbid alcohol use disorders are at a greater risk for attempting/completing
suicide and are likely to have other substance-related disorder diagnoses. Most estimates of the
prevalence of suicide among people with alcohol-related disorders range from 10–15%, although
alcohol use itself may be involved in a much higher percentage of suicides. Twenty to 50 percent
of all people with alcohol-related disorders also meet the diagnostic criteria for an anxiety
disorder. Phobias and panic disorder are particularly frequent comorbid diagnoses in patients
with alcohol use disorders

Question 24

Which of the following best describes the mechanism of action of
Acamprosate?
A. GABAA partial agonism
B. Blockade of ADH
C. Competitive antagonism of ALDH
D. Modulating opioid system to reduce craving
E. Reducing post-synaptic glutamate neurotransmission at NMDA receptor

Answer 24

E. Acamprosate’s principal neurochemical effects have been attributed to antagonism of
NMDA glutamate receptors, which restores the balance between excitatory and inhibitory
neurotransmission that is dysregulated following chronic alcohol consumption. Recently, however,
further mechanisms have been demonstrated. Thus acamprosate is said to have four principal
effects: A) reducing post-synaptic excitatory amino acid neurotransmission at N-methyl-Daspartate
(NMDA); B) diminishing Ca2+ infl ux into the cell, which interferes with expression of
the immediate early gene c-fos; C) decreasing the sensitivity of voltage-gated calcium channels,
and D) modulating metabotropic-5 glutamate receptors (mGluR5). The most common side
effects are headache, diarrhoea, fl atulence, abdominal pain, paraesthesias, and various skin
reactions. Acamprosate is not metabolised by liver and is excreted unchanged by the kidney.
Administration of disulfi ram or diazepam does not affect the pharmacokinetics of acamprosate.
Coadministration of naltrexone with acamprosate produces an increase in concentrations of
acamprosate. Effect of acamprosate is dose dependent and has been confi rmed by at least two
studies in humans.

Question 25

Sam has been diagnosed with alcohol dependence. He has been started on
disulfi ram following a planned detoxifi cation. You educate him about the
effects and side-effects of the medication. Unfortunately, Sam decides to
start drinking again after taking disulfi ram for 3 weeks. How long should he
wait after stopping disulfi ram before he can be sure of having no unpleasant
side-effects?
A. 1–2 hours
B. 1–2 days
C. 2–7 days
D. 1–2 weeks
E. 1–2 months

Answer 25

D. Disulfi ram inhibits aldehyde dehydrogenase producing a marked increase in blood
acetaldehyde concentration if alcohol is consumed. The accumulation of acetaldehyde produces
a wide array of unpleasant reactions, called the disulfi ram–ethanol reaction, characterized
by nausea, throbbing headache, vomiting, hypertension, fl ushing, sweating, thirst, dyspnoea,
tachycardia, chest pain, vertigo, and blurred vision. The reaction occurs almost immediately after
the ingestion of one alcoholic drink and can last from 30 minutes to 2 hours. A person taking
disulfi ram must be instructed that the ingestion/use of any quantity of alcohol (including alcoholcontaining
preparations of medicines, food, and cosmetics) would lead to the unpleasant reaction
with dangerous consequences at times. Disulfi ram should not be administered until the person
has abstained from alcohol for at least 12 hours. This reaction can occur as long as 1–2 weeks
after the last dose of disulfi ram.

Question 26

Learning to walk in a straight line despite the motor impairment produced
by alcohol intoxication is best explained by which of the following?
A. Pharmacodynamic tolerance
B. Pharmacokinetic tolerance
C. Behavioural tolerance
D. Conditioned tolerance
E. Reverse tolerance

Answer 26

C. Learned tolerance refers to a reduction in the effects of a drug because of
compensatory mechanisms that are acquired by past experiences. One type of learned tolerance
is called behavioural tolerance. This simply describes the skills that can be developed through
repeated experiences of attempting to function despite a state of mild to moderate intoxication.
A common example is learning to walk in a straight line despite the motor impairment produced
by alcohol intoxication. This probably involves both acquisition of motor skills and the learned
awareness of one’s defi cit, causing the person to walk more carefully. At higher levels of
intoxication, behavioural tolerance is overcome, and the defi cits are obvious. Pharmacokinetic,
or dispositional, tolerance refers to changes in the distribution or metabolism of a drug after
repeated administrations such that a given dose produces a lower blood concentration than the
same dose did on initial exposure. This may be mediated via enzyme induction. Pharmacodynamic
tolerance refers to adaptive changes that have taken place within the systems affected by the drug
so that the response to a given concentration of the drug is reduced, e.g. change in receptor
density. Conditioned tolerance is the process where environmental cues, e.g. sight, smell, etc, for
the substance will no longer produce a manifestation of the drug’s effect. Reverse tolerance, or
sensitization, refers to an increase in response with repetition of the same dose of the drug.

Question 27

Which of the following is NOT a principle used during motivational
interviewing of substance users?
A. Expressing empathy
B. Helping the client to see discrepancies in their behaviours
C. Avoiding argument
D. Resisting resistance
E. Supporting the patient’s sense of self-effi cacy

Answer 27

D. Miller and Rollnick (1991) described fi ve principles that are essential to motivational
interviewing. They are (1) express empathy: communicate acceptance, use refl ective listening, and
normalize a client’s ambivalence; (2) develop discrepancy: increase the client’s awareness of the
consequences of the problematic behaviour, orient the client to the discrepancy between his/
her current behaviour and goals in life, and have the client generate reasons for change; (3) avoid
argumentation; (4) roll with resistance: invite the client to consider new points of view rather
than having them imposed; and (5) support self-effi cacy.

Question 28

Which of the following is NOT a risk factor for the development of alcohol
hallucinosis?
A. Severe alcohol dependence
B. Later age of onset of alcohol problems
C. Binge drinking
D. Higher rate of other substance use
E. Family history of schizophrenia

Answer 28

B. Although the occurrence of alcoholic hallucinosis has been noted for centuries, its
nosological status is not yet clear. Little research regarding this has been published in recent
years. Tsuang et al. (1994) reported a prevalence of 7.4% among patients in an alcohol treatment
programme. Patients with alcoholic hallucinosis were younger at the onset of alcohol problems,
consumed more alcohol per occasion, developed more alcohol-related life problems, had
higher rates of drug experimentation, and used more of other drugs than alcohol users without
hallucinosis. The severity of dependence increased the risk for hallucinosis. It is also noted that
the prevalence of schizophrenia is higher in the families of index cases with alcoholic hallucinosis

Question 29

A decrease in which of the following subtypes of dopamine receptors makes
an individual susceptible to relapse in a population with substance use?
A. D1
B. D2
C. D3
D. D4
E. D5

Answer 29

B. Decreased D2 receptors in alcohol, cocaine, and methamphetamine users, whether
premorbid or the consequence of substance use, in conjunction with a fi nding of increased
salience to drug cues, indicate susceptibility to relapse in this population

Question 30

Which of the following is NOT shown to be associated with an increase in
the risk of development of alcohol abuse in elderly people?
A. Family history of alcohol use
B. Presence of an organic mental disorder
C. Having a drinking partner
D. Grief
E. Social isolation

Answer 30

B. Genetic and familial factors probably account for most cases of alcohol problems that
begin in adulthood and continue through to older age. Late-onset cases are associated with much
lower rates of family alcoholism. Compared with early-onset cases, late-onset problem drinkers
also tend to have less psychopathology. In fact, the notion that late-onset alcohol dependence
usually occurs secondary to a mood or organic mental disorder has not been upheld in recent
systematic studies. The inability to cope with major losses, chronic psychosocial strains, or
transient negative affects such as depression or loneliness, are associated with new or renewed
problem drinking. The pathophysiological effects of alcohol may be more serious in elderly
people because of an age-related increase in biological sensitivity to alcohol and in peak blood
level following a standard alcohol load. In addition, alcohol also aggravates many pre-existing
diseases that are more common in later life.

Question 31

Mr Smith is diagnosed with alcohol dependence syndrome. He receives
an educational session regarding the effects of drinking and the potential
benefi ts of abstinence. He does not make any immediate change in his
attitude or behaviour but is prepared to consider altering his drinking
habits. Which of the following phases of Prochaska’s transtheoretical model
of change is he in?
A. Preparation
B. Precontemplation
C. Contemplation
D. Action
E. Maintenance

Answer 31

C. The stages of change model by Prochaska and DiClemente are stages that a person
goes through when involved in a behavioural change. This may include a change in substance
misuse behaviour, starting daily exercise, going on a diet, or changing a health-related behaviour,
e.g. attempting to obtain a cervical smear. The fi rst stage is the precontemplation stage, where
the person is not thinking of any imminent change and is happy the way things are. The second
stage is contemplation, where he is considering a change in the near future. Preparation is
when he gets ready or prepares to enforce the behavioural change. The action phase is when
he implements the change, and in the maintenance phase he decides to continue the change in
behaviour and attempts to prevent relapse

Question 32

Which of the following best describes the learning theory behind the
effi cacy of supervised disulfi ram treatment?
A. Aversion theory
B. Positive reinforcement
C. Negative reinforcement
D. Punishment theory
E. Deterrence theory

Answer 32

E. Disulfi ram is generally considered a deterrent. Earlier works suggested disulfi ram to
be an aversion treatment. The theory underlying ‘aversion therapy’ is that ‘repeated pairing’ of
alcohol with an unpleasant stimulus leads to a conditioned response in which drinking alcohol
is increasingly perceived as unpleasant. This was previously considered to be the case with
disulfi ram, because it was common practice to induce the highly unpleasant but controlled
disulfi ram–ethanol reaction in a clinical setting before initiating regular therapy. This is now
considered unnecessary for the effi cacy of disulfi ram therapy, i.e. the ‘unpleasant’ outcome need
not be experienced by the person, but a ‘fear’ of the possibility of such experience is suffi cient.
An analogy is with police cars. Brewer states that no sane driver will exceed the speed limit if
he sees a police car in front or behind; one does not need to be arrested for speeding before
reducing the speed. Most patients who take disulfi ram under supervision do not risk drinking.
Those who do drink do not necessarily get a signifi cant reaction on standard doses of disulfi ram,
but if the experience is unpleasant, they do not usually repeat it. Some people may consider
this as a form of negative reinforcement, which again needs the subject to experience the
‘repeated conditioning’ in order to increase the abstinence behaviour. So, from the given choices,
deterrence theory would be the best choice. Deterrence is an established theme in criminal
justice. It refers to reduction in unwanted behaviour through knowledge of costs and risks
involved in an act.

Question 33

Which of the following is the most common intracranial complication of
cocaine use?
A. Non-haemorrhagic infarct
B. Transient ischaemic attack (TIA)
C. Subarachnoid haemorrhage
D. Intraventricular haemorrhage
E. Intraparenchymal haemorrhag

Answer 33

A. High doses of cocaine have been associated with a wide variety of toxic effects, including
cardiac arrhythmias, coronary artery spasms, myocardial infarction, and myocarditis. Most of
the complications are related to vasoconstriction. The most common cerebrovascular diseases
associated with cocaine use are non-haemorrhagic cerebral infarctions. When haemorrhagic
infarctions do occur, they can include subarachnoid, intraparenchymal, intraventricular, and at
times spinal cord haemorrhages. Other toxic effects on the central nervous system may include
seizures, hyperpyrexia, respiratory depression, and death. Cocaine-related seizures and loss
of consciousness are seen in heavy users. Rhabdomyolysis, after large doses of cocaine, may
contribute to renal complications. Sniffi ng cocaine can cause ulcers of the mucosa in the nose
and perforation of the nasal septum from persistent vasoconstriction. Inhaled cocaine freebase is
believed to induce lung damage. By producing placental vasoconstriction, cocaine may contribute
to foetal anoxia.

Question 34

Chris and Ken are classmates at the local primary school. Chris’s father has
problems related to alcohol use, while Ken’s parents are teetotal. How many
times is Chris more likely to develop an alcohol-related problem in later life
than Ken, assuming other psychosocial factors are comparable?
A. 2–3 times
B. 4–10 times
C. 10–20 times
D. 20–40 times
E. 100 times

Answer 34

B. Alcohol use disorders run in families. A child with an alcoholic parent has a 4- to
10-fold increased risk of developing alcoholism themselves. This can be due to both genetic
and environmental factors. Environmental infl uences include the availability of alcohol, parental
attitudes, and peer pressure. Starting to drink before the age of 15 years is associated with a
fourfold increased risk for lifetime alcoholism compared with starting at the age of 21 years.
Severe childhood stressors, especially emotional, physical, and sexual abuse, are associated with
up to seven times increased risk of alcoholism in adulthood. Childhood antisocial behaviour
predicts regular alcohol use in early adolescence and the development of alcoholism later on.

Question 35

Which of the following is the most common lifetime comorbid diagnosis in
a person with cocaine dependence?
A. Alcohol use disorder
B. Depression
C. Antisocial personality disorder
D. Phobia
E. Schizophrenia

Answer 35

A. Cocaine use is associated with frequent co-occurrence of other psychiatric disorders.
The presence of other psychiatric disorders sharply increases the odds of substance dependence,
and substance-dependent people are more likely than the general population to meet the
diagnostic criteria for additional psychiatric disorders. Among cocaine users seeking treatment,
the rates of additional current and lifetime diagnoses are regularly found to be elevated. The
most common additional lifetime diagnoses associated with cocaine use are alcoholism (60%),
antisocial personality (30%), and major depression (30%).

Question 36

Which of the following is a factor that can increase the risk of
benzodiazepine withdrawal in a clinical setting?
A. Gradual tapering of the prescribed drug
B. Shorter duration of exposure
C. Low level of psychopathology before initiation of benzodiazepine D treatment
D. Low level of educational attainment
E. Low dose of the prescribed drug

Answer 36

D. Symptoms associated with the withdrawal of benzodiazepine therapy may refl ect one
of three phenomena – a recurrence (return of the original symptoms); a rebound (worsening of
the original symptoms), or true withdrawal (emergence of new symptoms). These symptoms may
include anxiety, dysphoria, irritability, altered sleep–wake cycle, daytime drowsiness, tachycardia,
elevated blood pressure, hyperrefl exia, muscle tension, agitation/motor restlessness, tremor,
myoclonus, muscle and joint pain. Patients may also experience various perceptual disturbances
such as hyperacusis, depersonalization, blurred vision, and hallucinations. In severe cases, delirium
similar to delirium tremens has been reported. Factors infl uencing the development of the
discontinuance or withdrawal syndrome include the dose of the drug, duration of the drug intake,
rapid tapering of the dose and greater psychopathology before initiation and termination of
medication, dependent personality traits, and lower education levels

Question 37

Which of the following is NOT a feature of alcoholic hallucinosis?
A. Clear consciousness
B. Autonomic hyperactivity
C. Third-person hallucinations
D. Secondary delusions
E. Good prognosis compared with other psychoses

Answer 37

B. Alcoholic hallucinosis is a condition in which auditory hallucinations are present during
clear consciousness in the absence of autonomic overactivity, usually in a person who has been
drinking excessively for many years. Initially the hallucinations are simple in nature, but later on
become complex voices that are derogatory. These voices are usually second person, but at times
are third person. They may also be command hallucinations. Delusions, if present are secondary
to the voice. In both ICD-10 and DSM-IV, the disorder is classifi ed as a substance-induced
psychotic disorder. The differential diagnosis includes withdrawal symptoms and delirium tremens.
In both these conditions the auditory hallucinations are transient and disorganized, and in the
latter, consciousness is impaired. Auditory hallucinations of alcoholic hallucinosis are persistent
and organized, and occur during clear consciousness. The hallucinations usually respond rapidly
to antipsychotic medication. The prognosis is good; usually the condition improves within days or
a couple of weeks, provided that the person remains abstinent. Symptoms that last for 6 months
generally continue for years. The other differential diagnosis one needs to rule out, especially in
the presence of derogatory hallucinations, is major depression with psychotic symptoms

Question 38

An 18-year-old boy was brought to the A&E by police after being picked up
wandering near Tower Bridge. He was angry, agitated, and suspicious. He
was concerned about people trying to ‘get him’. On examination, he showed
evidence of stereotyped behaviour, tachycardia, pupillary dilation and
elevated blood pressure. Soon after initial evaluation, he developed seizures.
What is the most likely substance that may have led to this presentation?
A. Alcohol
B. Cannabis
C. Heroin
D. Amphetamine
E. Inhalant

Answer 38

D. The features described in the clinical scenario are that of amphetamine intoxication.
The clinching points are the sympathetic activity due to release of catecholamines and the
stereotyped behaviour, which are characteristic of amphetamine use. According to DSM-IV, the
diagnostic criteria for intoxication with amphetamine includes behavioural or psychological
changes such as euphoria or affective blunting; changes in sociability; hypervigilance; interpersonal
sensitivity; anxiety, tension, or anger; stereotyped behaviours; and impaired judgment. Physical
symptoms/signs include tachycardia or bradycardia, pupillary dilation, elevated or lowered blood
pressure, perspiration or chills with nausea or vomiting. Psychomotor changes include agitation
or retardation. Patients may complain of muscular weakness, chest pain; some may develop
cardiac arrhythmias and seizures.

Question 39

Cocaine intake is associated with all of the following phenomena except
A. Dopamine reuptake inhibition
B. Serotonin reuptake inhibition
C. Noradrenaline reuptake inhibition
D. Corticotrophin releasing hormone secretion
E. Prolactin release

Answer 39

E. Cocaine inhibits the normal reuptake of monoamines from the synaptic cleft by binding
to transporter proteins. Its reinforcing effects are primarily due to its actions at the dopamine
transporter, producing high levels of dopamine in the synapse. Cocaine also inhibits reuptake
of noradrenaline and serotonin. The increase in noradrenaline concentration is important for
some of cocaine’s toxic effects. The drug produces increases in adrenocorticotropic hormone
(ACTH) and cortisol by stimulating release of hypothalamic corticotropin-releasing hormone
(CRH). Acutely, cocaine also stimulates the release of luteinizing hormone and follicle-stimulating
hormone (FSH) and suppresses the release of prolactin.

Question 40

Martin has been admitted to the addictions unit to undergo detoxifi cation
from opiates. He has been known to suffer from low blood pressure. Which
of the following would be the best agent to treat his withdrawal symptoms?
A. Buprenorphine
B. Naloxone
C. Clonidine
D. Dihydrocodeine
E. Lofexidine

Answer 40

A. Buprenorphine is preferable to α2 adrenergic agonists if there are concerns about
bradycardia or hypotension. Buprenorphine results in lower severity of withdrawal symptoms
than α2 adrenergic agonists. Buprenorphine can be used for short-term opioid withdrawal and
has a better outcome than clonidine. Methadone and α2 adrenergic agonists (e.g. clonidine and
lofexidine) also have a good evidence base for reducing withdrawal symptoms. If a short duration
of treatment is desirable, α2 adrenergic agonists are preferable to methadone. Methadone
treatment is more successful if carried out slowly or with a linear dose reduction. Methadone can
be used during pregnancy, and there are emerging studies regarding the use of buprenorphine.
α2 adrenergic agonists should not be prescribed in pregnancy.

Question 41

Tolerance doesn’t develop to which of the following symptoms/signs in
opiate dependence?
A. Sedation
B. Euphoria
C. Constipation
D. Miosis
E. Insomnia

Answer 41

C. Recent research has shed new light on the mechanisms involved in the development of
opioid tolerance and dependence. Stimulation of opioid receptors located on critical cells such as
those located in the locus coeruleus produces a decrease in cell fi ring. This effect refl ects cellular
hyperpolarization that results from both the activation of potassium channels and the inhibition
of slowly depolarizing sodium channels. These actions occur in conjunction with a decrease in
intracellular cyclic adenosine monophosphate (cAMP) levels. Among the given choices, both
constipation and miosis have been traditionally thought to be resistant to tolerance. Kollars and
Larson reviewed the two studies conducted in the late 60s which are often quoted to show that
miosis does not develop tolerance. They quote a number of other studies which have shown that
miosis is susceptible to tolerance. There are comparatively few data refuting the lack of tolerance
response for constipation. Clinical experience hints that constipation is a major problem that
persists without development of tolerance, especially in elderly people who are prescribed
opiates as analgesics. This can be very diffi cult to treat, at times requiring enemas and in severe
cases requiring manual evacuation.

Question 42

Donna is an active opiate user, who recently found out that she is pregnant.
She approaches her GP saying she wants to stop her substance use and is
not considering maintenance therapy with methadone. She is worried about
withdrawal symptoms. Her GP calls you about the best time for Donna to
undergo opiate withdrawal during pregnancy. Which of the following is the
most appropriate answer?
A. First trimester
B. Second trimester
C. Third trimester
D. Any of the above
E. Withdrawal should never be considered during pregnancy

Answer 42

B. The view of treatment of opiate dependence has changed over the past 25 years.
Previously it was thought that all patients should undergo withdrawal prior to delivery. Current
practice acknowledges the fact that an abstinence state is almost impossible to achieve in this
population. Hence most experts now advocate methadone maintenance as a way to reduce
illegal drug use and remove the woman from a hazardous drug-seeking environment. Current
consensus is that undertaking a medical withdrawal regimen could be accomplished most safely
during the second trimester, with careful monitoring of foetal welfare by perinatal experts.
The consensus is that opiate withdrawal could be best accomplished through stabilization
with methadone followed by gradual reduction of the methadone dosage by 2–2.5 mg every
7–10 days. This should ideally be done only in a secondary care setting with the involvement of
obstetricians and neonatologists.

Question 43

Which of the following symptoms is NOT found in opiate withdrawal?
A. Abdominal pain
B. Dry eyes
C. Dilated pupils
D. Vomiting
E. Sweating

Answer 43

B. Lacrimation – not dry eyes – is a symptom seen in opiate withdrawal. DSM-IV states that
opiate withdrawal can be precipitated by cessation of (or reduction in) opioid use that has been
heavy and prolonged (several weeks or longer) or administration of an opioid antagonist after a
period of opioid use. Other symptoms typically associated with withdrawal are dysphoric mood,
nausea or vomiting, muscle aches, rhinorrhoea, pupillary dilation, piloerection, sweating, diarrhoea,
yawning, fever, and insomnia. Piloerection along with general ‘secretion’ from most of the glands is
called the ‘cold turkey’, when people tend to detox without medical help.

Question 44

Which of the following treatments for opioid dependence has been shown
to reduce risk-taking behaviours associated with HIV transmission?
A. Naltrexone use
B. Methadone maintenance
C. Narcotics anonymous programme
D. Antidepressant treatment
E. Oral morphine prescription

Answer 44

B. Systematic reviews of methadone maintenance vs. non-opioid therapy conducted by
the Cochrane collaboration shows that methadone has a superior retention rate than control
conditions. Methadone maintenance treatment has also been shown to reduce risk behaviours
(specifi cally reduction in needle sharing) and thereby has achieved a reduction in the transmission
of HIV. Intake of illicit opioids decreased in the methadone maintenance group, as shown by
fewer positive urine tests for ‘morphine’ in these groups. Although criminal activity was found to
be less in the group that was on methadone maintenance, the statistics did not show a signifi cant
difference. Nevertheless, individual randomized controlled trials have shown that methadone
maintenance decreases criminal activity. In addition, methadone maintenance has shown to
decrease rates of suicide and overdose in this population.

Question 45

The half life of methadone in a patient with opioid dependence is
A. 4–6 hours
B. 10–20 hours
C. 24–36 hours
D. 72–90 hours
E. None of the above

Answer 45

C. Elimination of most synthetic opioids is complex. The peak plasma concentrations of oral
methadone are reached within 2–6 hours, and initially plasma half-life is 4–6 hours in opioid-naive
people and 24–36 hours after steady dosing of any type of opioid. It generally requires oncedaily
dosing. Methadone is highly protein bound and equilibrates widely throughout the body,
which ensures little post-dosage variation in steady-state plasma concentrations. Methadone can
be used for short-term detoxifi cation (7–30 days), long-term detoxifi cation (up to 180 days),
and maintenance (treatment beyond 180 days) of opioid-dependent individuals. In contrast, the
elimination of a sublingual dosage of buprenorphine occurs in two phases: an initial phase with a
half-life of 3–5 hours and a terminal phase with a half-life of more than 24 hours. Buprenorphine
dissociates from its receptor binding site slowly, which permits an every-other-day dosing

Question 46

Which of the receptors is implicated in the respiratory depressant action of
opioids?
A. Mu
B. Kappa
C. Delta
D. Sigma
E. ORL1

Answer 46

A. Mu (MOP) receptors are found in the brain in the cortex, thalamus, striosomes, and
periaqueductal grey. The Mu1 subtype is responsible for supraspinal analgesia and physical
dependence. The Mu 2 subtype is responsible for respiratory depression, euphoria, constipation,
physical dependence, and miosis. Kappa (KOP) receptors are found in the hypothalamus,
claustrum, and periaqueductal grey regions of the brain and the substantia gelatinosa of the
spinal cord. They are involved in spinal analgesia, sedation, miosis, and inhibition of ADH release.
Delta (DOP) receptors are seen in the brain in the regions of the pons, amygdala, olfactory
bulbs, and the deep cortex. Their function includes analgesia, euphoria, and physical dependence.
Sigma receptors, which mediate the antitussive action, are no longer considered to be opioid
receptors. A new receptor called ORL1 has recently been identifi ed, with an endogenous ligand
called nociceptin. The ORL1 receptors do not bind opioid peptides or opiate drugs. This system
is widely distributed in the brain and spinal cord. Its activation produces hyperalgesia in most
instances. Many do not consider ORL1 as an opiate receptor. The International Union of Basic
and Clinical Pharmacology has recently agreed to rename mu, kappa, and delta to MOP, KOP and
DOP receptors respectively.

Question 47

What is the equivalent dose of methadone for 0.5 g of street heroin?
A. 5–15 mL of 1 mg/mL mixture
B. 10–20 mL of 1 mg/mL mixture
C. 30–40 mL of 1 mg/mL mixture
D. 80–100 mL of 1 mg/ml mixture
E. 1–2 mL of 1mg/mL mixture

Answer 47

C. Assessing the methadone dose equivalent of reported street heroin use is diffi cult
because of the reliance on self-report and the variable purity of illicit heroin. Broadly speaking,
30–40 mL of 1 mg/mL mixture is approximately equivalent to 0.5 g of street heroin.

Question 48

Amotivational syndrome has been described with the use of which of the
following substance?
A. Cocaine
B. Amphetamine
C. Cannabis
D. Alcohol
E. LSD

Answer 48

C. A controversial cannabis-related syndrome is amotivational syndrome. Whether the
syndrome is related to cannabis use or refl ects characterological traits in a subgroup of people
regardless of cannabis use is under debate. Traditionally, amotivational syndrome has been
associated with long-term heavy use and has been characterized by a person’s unwillingness to
persist in a task. Persons are described as becoming apathetic and anergic, and appearing indolent.
Field studies of chronic heavy cannabis users in societies with a tradition of such use have not
produced consistent evidence to demonstrate the existence of amotivational syndrome. Critics
have questioned the methodological issues of the study. However, the possibility has been kept
alive by reports that regular cannabis users experience a loss of ambition and impaired school
and occupational performance.

Question 49

Maternal smoking during pregnancy has been best associated with which of
the following?
A. Learning disability
B. Autistic spectrum disorder
C. Conduct disorder
D. Autism
E. Mood disorders

Answer 49

C. Maternal smoking during pregnancy has been consistently associated with conduct
disorder and delinquency and attention-defi cit hyperactivity disorder (ADHD) in offspring
during childhood and adolescence. This association has been found even after controlling for
confounding variables such as socioeconomic status, maternal age, birth weight, and maternal
psychopathology. This may be due to the effect of nicotine or may be genetically mediated. There
may be other environmental risks that play a part in its development. More recent research has
shown that the behavioural problems may not be a direct risk of smoking itself, but the presence
of other genetic factors that may mediate the association between maternal smoking and
conduct problems in children.

Question 50

Following recent consumption of LSD, it can be detected in urine for up to
A. 24 hours
B. 1–3 days
C. 10–15 days
D. 15–30 days
E. More than 30 days

Answer 50

B. LSD and its metabolites are detectable in human urine for as long as 4 days after the
ingestion of 0.2 mg of the drug. Amphetamines can be detected for 2–4 days; cocaine can be
present for up to 3 days. Marijuana users may test positive in urine samples for up to 3 days after
casual use; this can extend to up to 30 days for regular high-dose users.